基层卫生服务决策支持系统构建

阐述基层卫生服务决策支持系统设计原则、思路和总体架构,以糖尿病为例开发具备辅助诊断、风险评估、疾病管理和双向转诊功能的基层决策支持系统,辅助基层医生预防、评估和治疗糖尿病,对实现居民分级分类管理、提供个性化治疗具有重要意义。     

Effectiveness of Topic-specific Infobuttons: A Randomized Controlled Trial

Objective

Infobuttons are decision support tools that provide links within electronic medical record systems to relevant content in online information resources. The aim of infobuttons is to help clinicians promptly meet their information needs. The objective of this study was to determine whether infobutton links that direct to specific content topics (“topic links”) are more effective than links that point to general overview content (“nonspecific links”).

Design

Randomized controlled trial with a control and an intervention group. Clinicians in the control group had access to nonspecific links, while those in the intervention group had access to topic links.

Measurements

Infobutton session duration, number of infobutton sessions, session success rate, and the self-reported impact that the infobutton session produced on decision making.

Results

The analysis was performed on 90 subjects and 3,729 infobutton sessions. Subjects in the intervention group spent 17.4% less time seeking for information (35.5 seconds vs. 43 seconds, p = 0.008) than those in the control group. Subjects in the intervention group used infobuttons 20.5% (22 sessions vs. 17.5 sessions, p = 0.21) more often than in the control group, but the difference was not significant. The information seeking success rate was equally high in both groups (89.4% control vs. 87.2% intervention, p = 0.99). Subjects reported a high positive clinical impact (i.e., decision enhancement or knowledge update) in 62% of the sessions.

Limitations

The exclusion of users with a low frequency of infobutton use and the focus on medication-related information needs may limit the generalization of the results. The session outcomes measurement was based on clinicians'' self-assessment and therefore prone to bias.

Conclusion

The results support the hypothesis that topic links are more efficient than nonspecific links regarding the time seeking for information. It is unclear whether the statistical difference demonstrated will result in a clinically significant impact. However, the overall results confirm previous evidence that infobuttons are effective at helping clinicians to answer questions at the point of care and demonstrate a modest incremental change in the efficiency of information delivery for routine users of this tool.     

A Randomized Trial of Population-Based Clinical Decision Support to Manage Health and Resource Use for Medicaid Beneficiaries

To determine whether a clinical decision support system can favorably impact the delivery of emergency department and hospital services. Randomized clinical trial of three clinical decision support delivery modalities: email messages to care managers (email), printed reports to clinic administrators (report) and letters to patients (letter) conducted among 20,180 Medicaid beneficiaries in Durham County, North Carolina with follow-up through 9 months. Patients in the email group had fewer low-severity emergency department encounters vs. controls (8.1 vs. 10.6/100 enrollees, p?<?0.001) with no increase in outpatient encounters or medical costs. Patients in the letter group had more outpatient encounters and greater outpatient and total medical costs. There were no treatment-related differences for patients in the reports group. Among patients <18 years, those in the email group had fewer low severity (7.6 vs. 10.6/100 enrollees, p?<?0.001) and total emergency department encounters (18.3 vs. 23.5/100 enrollees, p?<?0.001), and lower emergency department ($63 vs. $89, p?=?0.002) and total medical costs ($1,736 vs. $2,207, p?=?0.009). Patients who were ≥18 years in the letter group had greater outpatient medical costs. There were no intervention-related differences in patient-reported assessments of quality of life and medical care received. The effectiveness of clinical decision support messaging depended upon the delivery modality and patient age. Health IT interventions must be carefully evaluated to ensure that the resultant outcomes are aligned with expectations as interventions can have differing effects on clinical and economic outcomes.     

A Visual Decision Support Tool for Appendectomy Care

Appendectomy is the most common abdominal surgical procedure performed in children in the United States. In order to assist care providers in creating treatment plans for the postoperative management of pediatric appendicitis, we have developed a predictive statistical model of outcomes on which we have built a prototype decision aid application. The model, trained on 3724 anonymized care records and evaluated on a separate set of 2205 cases from a tertiary care center, achieves 97.0% specificity, 25.1% true sensitivity, and 58.8% precision. We have also built an interactive decision support tool augmented with simple visualization techniques designed for clinicians to use in the course of making care decisions (e.g., discharge) and in patient/stakeholder communication. Its focus is on end-user ease of use and integration into existing clinician workflows, and is designed to evolve its predictions as more and better data become available.     

Impact of a Computerized Clinical Decision Support System on Reducing Inappropriate Antimicrobial Use: A Randomized Controlled Trial

ObjectiveMany hospitals utilize antimicrobial management teams (AMTs) to improve patient care. However, most function with minimal computer support. We evaluated the effectiveness and cost-effectiveness of a computerized clinical decision support system for the management of antimicrobial utilization.DesignA randomized controlled trial in adult inpatients between May 10 and August 3, 2004. Antimicrobial utilization was managed by an existing AMT using the system in the intervention arm and without the system in the control arm. The system was developed to alert the AMT of potentially inadequate antimicrobial therapy.MeasurementsOutcomes assessed were hospital antimicrobial expenditures, mortality, length of hospitalization, and time spent managing antimicrobial utilization.ResultsThe AMT intervened on 359 (16%) of 2,237 patients in the intervention arm and 180 (8%) of 2,270 in the control arm, while spending approximately one hour less each day on the intervention arm. Hospital antimicrobial expenditures were $285,812 in the intervention arm and $370,006 in the control arm, for a savings of $84,194 (23%), or $37.64 per patient. No significant difference was observed in mortality (3.26% vs. 2.95%, p = 0.55) or length of hospitalization (3.84 vs. 3.99 days, p = 0.38).ConclusionUse of the system facilitated the management of antimicrobial utilization by allowing the AMT to intervene on more patients receiving inadequate antimicrobial therapy and to achieve substantial time and cost savings for the hospital. This is the first study that demonstrates in a patient-randomized controlled trial that computerized clinical decision support systems can improve existing antimicrobial management programs.     

Randomized Trial of a Clinical Decision Support System: Impact on the Management of Children with Fever without Apparent Source

Objective

To assess compliance with a clinical decision support system (CDSS) for diagnostic management of children with fever without apparent source and to study the effects of application of the CDSS on time spent in the emergency department (ED) and number of laboratory tests.

Design

The CDSS was used by ED nursing staff to register children presenting with fever. The CDSS identified children that met inclusion criteria (1–36 months and fever without apparent source (FWS)) and provided patient-specific diagnostic management advice. Children at high risk for serious bacterial infection were randomized for the ‘intervention’ (n = 74) or the ‘control’ (n = 90) group. In the intervention group, the CDSS provided the advice to immediately order laboratory tests and in the control group the ED physician first assessed the children and then decided on ordering laboratory tests.

Results

Compliance with registration of febrile children was 50% (683/1,399). Adherence to the advice to order laboratory tests was 82% (61/74). Children in the intervention group had a median (25^th–75^th percentile) length of stay at the ED of 138 (104–181) minutes. The median length of stay at the ED in the control group was 123 (83–179) minutes. Laboratory tests were significantly more frequently ordered in the intervention group (82%) than in the control group (44%, p < 0.001, χ² test).

Conclusion

Implementation of a CDSS for diagnostic management of young children with fever without apparent source was successful regarding compliance and adherence to CDSS recommendations, but had unexpected effects on patient outcome in terms of ED length of stay and number of laboratory tests. The use of the current CDSS was discontinued.     

Behavioral vs Drug Treatment for Urge Urinary Incontinence in Older Women: A Randomized Controlled Trial

Context.— Urinary incontinence is a common condition caused by many factors with several treatment options. Objective.— To compare the effectiveness of biofeedback-assisted behavioral treatment with drug treatment and a placebo control condition for the treatment of urge and mixed urinary incontinence in older community-dwelling women. Design.— Randomized placebo-controlled trial conducted from 1989 to 1995. Setting.— University-based outpatient geriatric medicine clinic. Patients.— A volunteer sample of 197 women aged 55 to 92 years with urge urinary incontinence or mixed incontinence with urge as the predominant pattern. Subjects had to have urodynamic evidence of bladder dysfunction, be ambulatory, and not have dementia. Intervention.— Subjects were randomized to 4 sessions (8 weeks) of biofeedback-assisted behavioral treatment, drug treatment (with oxybutynin chloride, possible range of doses, 2.5 mg daily to 5.0 mg 3 times daily), or a placebo control condition. Main Outcome Measures.— Reduction in the frequency of incontinent episodes as determined by bladder diaries, and patients' perceptions of improvement and their comfort and satisfaction with treatment. Results.— For all 3 treatment groups, reduction of incontinence was most pronounced early in treatment and progressed more gradually thereafter. Behavioral treatment, which yielded a mean 80.7% reduction of incontinence episodes, was significantly more effective than drug treatment (mean 68.5% reduction; P=.04) and both were more effective than the placebo control condition (mean 39.4% reduction; P<.001 and P=.009, respectively). Patient-perceived improvement was greatest for behavioral treatment (74.1% "much better" vs 50.9% and 26.9% for drug treatment and placebo, respectively). Only 14.0% of patients receiving behavioral treatment wanted to change to another treatment vs 75.5% in each of the other groups. Conclusion.— Behavioral treatment is a safe and effective conservative intervention that should be made more readily available to patients as a first-line treatment for urge and mixed incontinence.      

丝裂霉素C三种应用方法对防止翼状胬肉术后复发的比较

目的；研究Mitomycin C不同的应用方法对防止翼状胬肉术后复发的作用。方法：采用随机分组的方法对83例112眼原发性胬肉进行对照研究，Mitomycin C的应用方法分别为术中应用，术后1周内及手术1周后应用。结果：Mitomycin C三种应用方法均可降低翼状胬肉术后的复发率，但术后1周应用Mitomycin C组角膜创面愈合延迟。结论：应用Mitomycin C可有效地防止翼状胬肉切除后复发。     

Protocol-Driven Decision Support within e-Referral Systems to Streamline Patient Consultation,Triaging and Referrals from Primary Care to Specialist Clinics

Patient referral is a protocol where the referring primary care physician refers the patient to a specialist for further treatment. The paper-based current referral process at times lead to communication and operational issues, resulting in either an unfulfilled referral request or an unnecessary referral request. Despite the availability of standardized referral protocols they are not readily applied because they are tedious and time-consuming, thus resulting in suboptimal referral requests. We present a semantic-web based Referral Knowledge Modeling and Execution Framework to computerize referral protocols, clinical guidelines and assessment tools in order to develop a computerized e-Referral system that offers protocol-based decision support to streamline and standardize the referral process. We have developed a Spinal Problem E-Referral (SPER) system that computerizes the Spinal Condition Consultation Protocol (SCCP) mandated by the Halifax Infirmary Division of Neurosurgery (Halifax, Canada) for referrals for spine related conditions (such as back pain). The SPER system executes the ontologically modeled SCCP to determine (i) patient’s triaging option as per severity assessments stipulated by SCCP; and (b) clinical recommendations as per the clinical guidelines incorporated within SCCP. In operation, the SPER system identifies the critical cases and triages them for specialist referral, whereas for non-critical cases SPER system provides clinical guideline based recommendations to help the primary care physician effectively manage the patient. The SPER system has undergone a pilot usability study and was deemed to be easy to use by physicians with potential to improve the referral process within the Division of Neurosurgery at QEII Health Science Center, Halifax, Canada.     

A Randomized Effectiveness Trial of a Clinical Informatics Consult Service: Impact on Evidence-based Decision-making and Knowledge Implementation

Objective

To determine the effectiveness of providing synthesized research evidence to inform patient care practices via an evidence based informatics program, the Clinical Informatics Consult Service (CICS).

Design

Consults were randomly assigned to one of two conditions: CICS Provided, in which clinicians received synthesized information from the biomedical literature addressing the consult question or No CICS Provided, in which no information was provided.

Measurement

Outcomes were measured via online post-consult forms that assessed consult purpose, actual and potential impact, satisfaction, time spent searching, and other variables.

Results

Two hundred twenty six consults were made during the 19-month study period. Clinicians primarily made requests in order to update themselves (65.0%, 147/226) and were satisfied with the service results (Mean 4.52 of possible 5.0, SD 0.94). Intention to treat (ITT) analyses showed that consults in the CICS Provided condition had a greater actual and potential impact on clinical actions and clinician satisfaction than No CICS consults. Evidence provided by the service primarily impacted the use of a new or different treatment (OR 8.19 95% CI 1.04–64.00). Reasons for no or little impact included a lack of evidence addressing the issue or that the clinician was already implementing the practices indicated by the evidence.

Conclusions

Clinical decision-making, particularly regarding treatment issues, was statistically significantly impacted by the service. Programs such as the CICS may provide an effective tool for facilitating the integration of research evidence into the management of complex patient care and may foster clinicians’ engagement with the biomedical literature.     

基本药物制度在浙江省基层医疗机构实施现状分析

本文重点分析了基本药物制度在浙江省基层医疗机构的推广和实施情况,发现存在基层医疗机构服务量和收入下降幅度较大、缺乏对基本药物制度实施的强有力的辅助政策支持、国家基本药物目录品种偏少导致制度上的“缺医少药”、基本药物与居民需求脱节、基本药物供应链条松散等问题,提出要实现基本药物制度的推广,必须与基层医疗服务机构的服务提供方式和模式紧密结合起来,按照医疗卫生体制改革的总体思路,从医疗服务的特性出发,整合医疗服务资源,推行基本药物制度。     

Adoption of Order Entry with Decision Support for Chronic Care by Physician Organizations

Objective

This study sought to explore physician organizations’ adoption of chronic care guidelines in order entry systems and to investigate the organizational and market-related factors associated with this adoption.

Design

A quantitative nationwide survey of all primary care medical groups in the United States with 20 or more physicians; data were collected on 1,104 physician organizations, representing a 70% response rate.

Measurements

Measurements were the presence of an asthma, diabetes, or congestive heart failure guideline in a physician organization’s order entry system; size; age of the organization; number of clinic locations; type of ownership; health maintenance organization market penetration; urban/rural location; and presence of external incentives to improve quality of care.

Results

Only 27% of organizations reported access to order entry with decision support for chronic disease care. External incentives for quality is the only factor significantly associated with adoption of these tools. Organizations experiencing greater external incentives for quality are more likely to adopt order entry with decision support.

Conclusion

Because external incentives are strong drivers of adoption, policies requiring reporting of chronic care measurements and rewarding improvement as well as financial incentives for use of specific information technology tools are likely to accelerate adoption of order entry with decision support.     

Effect of Local Medical Opinion Leaders on Quality of Care for Acute Myocardial Infarction: A Randomized Controlled Trial

Context.— The effectiveness of recruiting local medical opinion leaders to improve quality of care is poorly understood. Objective.— To evaluate a guideline-implementation intervention of clinician education by local opinion leaders and performance feedback to (1) increase use of lifesaving drugs (aspirin and thrombolytics in eligible elderly patients, -blockers in all eligible patients) for acute myocardial infarction (AMI), and (2) decrease use of a potentially harmful therapy (prophylactic lidocaine). Design.— Randomized controlled trial with hospital as the unit of randomization, intervention, and analysis. Setting.— Thirty-seven community hospitals in Minnesota. Patients.— All patients with AMI admitted to study hospitals over 10 months before (1992-1993, N=2409) or after (1995-1996, N=2938) the intervention. Intervention.— Using a validated survey, we identified opinion leaders at 20 experimental hospitals who influenced peers through small and large group discussions, informal consultations, and revisions of protocols and clinical pathways. They focused on (1) evidence (drug efficacy), (2) comparative performance, and (3) barriers to change. Control hospitals received mailed performance feedback. Main Outcome Measures.— Hospital-specific changes before and after the intervention in the proportion of eligible patients receiving each study drug. Results.— Among experimental hospitals, the median change in the proportion of eligible elderly patients receiving aspirin was +0.13 (17% increase from 0.77 at baseline), compared with a change of -0.03 at control hospitals (P=.04). For -blockers, the respective changes were +0.31 (63% increase from 0.49 at baseline) vs +0.18 (30% increase from baseline) for controls (P=.02). Lidocaine use declined by about 50% in both groups. The intervention did not increase thrombolysis in the elderly (from 0.73 at baseline), but nearly two thirds of eligible nonrecipients were older than 85 years, had severe comorbidities, or presented after at least 6 hours. Conclusions.— Working with opinion leaders and providing performance feedback can accelerate adoption of some beneficial AMI therapies (eg, aspirin, -blockers). Secular changes in knowledge and hospital protocols may extinguish outdated practices (eg, prophylactic lidocaine). However, it is more difficult to increase use of effective but riskier treatments (eg, thrombolysis) for frail elderly patients.      

PELFw方案和5-FU/LV方案在高危胃癌辅助化疗中的随机对照研究

3 背景 虽然手术仍然是胃癌病人治疗的基础，但根治手术后病人的5年生存率仅15％～35％，而在辅助化疗方面，仍未有比较有效的肯定的化疗方案来提高手术的疗效。早期的FAM方案现已证实对胃癌辅助化疗是无效的；90年代早期，PELFw方案在进展期胃癌中的应用显示了超过50％的反应率及可接受的毒副反应。PELFw方案是否能在胃癌术后辅助化疗方面起到很好的效果值得研究。     

耳穴贴压法治疗中风后抑郁随机对照研究

目的：评价耳穴贴压法治疗中风后抑郁（PSD）的疗效。方法：将114例符合试验要求的PSD病人按随机号随机进入试验组及对照组,各57例。试验组采用耳穴贴压法,对照组口服百忧解。两组均治疗8周,以汉密顿抑郁量表-21项（HAMD）、中国脑卒中临床神经功能缺损程度评分量表（神经功能缺损）和日常生活活动能力量表（BI）为观察指标,在治疗前、第2周末、第4周末、第8周末各检测1次,共4次。结果：试验组与对照组共有107例完成试验（分别为55例、52例）。试验组与对照组治疗后HAMD评分均有下降,试验组与对照组治疗后分值的下降均有统计学意义,但两组治疗后HAMD评分下降的差异无统计学意义。试验组与对照组治疗后神经功能缺损均有下降,试验组与对照组治疗后分值的下降均无统计学意义。同样,两组治疗后神经功能缺损下降的差异无统计学意义。两组治疗后BI评分均有提高,两组治疗后分值的提高均有统计学意义,同样,两组治疗后BI评分下降的差异无统计学意义。结论：耳穴贴压法治疗PSD可获得与百郁解相似的疗效。     

耳穴贴压法治疗中风后抑郁随机对照研究

目的:评价耳穴贴压法治疗中风后抑郁(PSD)的疗效。方法:将114例符合试验要求的PSD病人按随机号随机进入试验组及对照组,各57例。试验组采用耳穴贴压法,对照组口服百忧解。两组均治疗8周,以汉密顿抑郁量表-21项(HAMD)、中国脑卒中临床神经功能缺损程度评分量表(神经功能缺损)和日常生活活动能力量表(BI)为观察指标,在治疗前、第2周末、第4周末、第8周末各检测1次,共4次。结果:试验组与对照组共有107例完成试验(分别为55例、52例)。试验组与对照组治疗后HAMD评分均有下降,试验组与对照组治疗后分值的下降均有统计学意义,但两组治疗后HAMD评分下降的差异无统计学意义。试验组与对照组治疗后神经功能缺损均有下降,试验组与对照组治疗后分值的下降均无统计学意义。同样,两组治疗后神经功能缺损下降的差异无统计学意义。两组治疗后BI评分均有提高,两组治疗后分值的提高均有统计学意义,同样,两组治疗后BI评分下降的差异无统计学意义。结论:耳穴贴压法治疗PSD可获得与百郁解相似的疗效。